City of Columbia Regulated Industrial Wastewater Discharge Monitoring Report Form
DMR
Company Name:
Address:
Name and Position Of
Principal Executive
Officer:
Contact Person:
Telephone
Pretreatment Plant
Operator:
Discharge Permit Number:
Reporting Interval:
To
YR/MO/DAY
YR/MO/DAY
Discharge Limits:
Parameter
Permitted Conditions
Monthly Avg.
Daily Max.
Mg/L Lbs/Day Mg/L
Lbs/Day
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Reported From Sampling
Monthly Avg. Daily Max
Mg/L Lbs/Day Lbs/Day
City of Columbia Regulated Industrial Wastewater Discharge Monitoring Report Form
DMR
Flow:
Permitted Conditions
Reported From Sampling
Maximum GPD:
Maximum GPM:
(Attach record of all daily flows that exceed the daily permitted flow.)
Compliance:
YES
NO
Sample Date(s):
Analysis Date(s):
Sample Time(s):
Analysis By:
Sample Type:
Receipt Date(s):
Sampled By:
Receipt By:
I certify under penalty of law that this document and all attachments were prepared under my
direction or supervision in accordance with a system designed to assure that qualified
personnel gather and evaluate the information submitted. Based on my inquiry of the person
or persons who manage the system, or those persons directly responsible for gathering the
information, the information submitted is, to the best of my knowledge, true, accurate, and
complete. I am aware that there are significant penalties for submitting false information,
including the possibility of fine and imprisonment for knowing violations.
Date
Signature of Principal Executive Officer or
Authorized Agent
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